Beta-Blocker Use in Patients with COPD

Clinical Question

Are beta blockers safe in patients with chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

In 20 studies of cardioselective beta blockers in patients with COPD, participants had no adverse pulmonary or respiratory effects. Because of their salutary cardiovascular effects, cardioselective beta blockers should not be withheld from patients with COPD.

Practice Pointers

Beta blockers reduce mortality in patients with ischemic heart disease, heart failure, acute coronary syndrome, myocardial infarction, or hypertension.^1,2 However, COPD often is cited as a contraindication to beta-blocker therapy.^3,4 Concern about inciting acute bronchospasm with these agents often leads physicians to avoid using them in patients with COPD and life-threatening coronary artery disease.

In 2001, a systematic review reported that cardioselective beta blockers did not have any deleterious effects in patients with reversible airway disease.⁵ In 2005, the same researchers focused on patients with COPD because these patients are more likely than those with asthma to have underlying ischemic heart disease and therefore may benefit from beta-blockade.

The researchers found 20 trials evaluating the use of beta blockers in patients with COPD: 11 studies with a total of 131 patients evaluating single-dose treatment, and nine studies with a total of 147 patients evaluating treatment of a longer duration. Most of these studies were small, with averages of 12 and 16 patients in the single- and continued-treatment groups, respectively. Trials were included in the analysis if: (1) forced expiratory volume in 1 second (FEV₁) was reported at rest; (2) the trials were randomized, controlled, and single- or double-blinded; and (3) participants met the American Thoracic Society definition of COPD or demonstrated a baseline FEV₁ of less than 80 percent. The authors evaluated only cardioselective beta1 blockers (e.g., atenolol [Tenormin], metoprolol [Toprol], bisoprolol [Zebeta], acebutolol [Sectral]) because these were most often used in clinical practice.

There was no reduction in FEV₁ or increase in respiratory symptoms in patients with COPD given cardioselective beta blockers in single or continued treatment. Four trials also demonstrated no adverse effects in the FEV₁ treatment response to beta2 agonists in those patients given beta blockers.

This meta-analysis was limited by small study size, inclusion of only published literature, possible publication bias, and non-delineated randomization in many of the studies. In addition, 80 percent of the patients were men. However, in light of their proven mortality prevention, the benefit of cardio-selective beta blockers in patients with COPD who present with an acute coronary syndrome seems to outweigh the perceived risks.